
==== Front
BMC Cardiovasc Disord
BMC Cardiovasc Disord
BMC Cardiovascular Disorders
1471-2261
BioMed Central London

39160460
4092
10.1186/s12872-024-04092-7
Research
Prevalence and associated factors of atrial fibrillation among patients with rheumatic heart disease attending public referral hospitals in Bahir Dar city, Northwest Ethiopia, 2023
Mengie Adanech 1
Admassu Eleni 2
Habtamu Desiyalew 3
Berhie Alemshet Yirga 4
Mulatu Kebadnew 5
Lidetu Tadios tadioslidetu@gmail.com
Tadios.Lidetu@bdu.edu.et

6
1 https://ror.org/01670bg46 grid.442845.b 0000 0004 0439 5951 Department of Internal Medicine, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
2 https://ror.org/01670bg46 grid.442845.b 0000 0004 0439 5951 Department of Reproductive Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
3 Department of Public Health Emergency, Humedica e.V, Addis Ababa, Ethiopia
4 https://ror.org/01670bg46 grid.442845.b 0000 0004 0439 5951 Department of Adult Health Nursing, College of Medicine and Health sciences, Bahir Dar University, Bahir Dar, Ethiopia
5 https://ror.org/01670bg46 grid.442845.b 0000 0004 0439 5951 Department of Epidemiology and Biostatistics, College of Medicine and Health sciences, Bahir Dar University, Bahir Dar, Ethiopia
6 https://ror.org/034yc4v31 grid.510429.b College of Health Sciences, Debark University, Debark, Ethiopia
19 8 2024
19 8 2024
2024
24 43415 4 2024
1 8 2024
© The Author(s) 2024, corrected publication 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Atrial fibrillation (AF) is a supraventricular arrhythmia associated with uncoordinated atrial activation. Atrial fibrillation is complication of rheumatic heart disease and is associated with substantial morbidity and mortality. It is a growing public health problem and economic and social burden. Studies investigating the prevalence and factors associated with atrial fibrillation among chronic rheumatic heart disease patients in Ethiopia are scarce. Therefore, this study aimed to determine the prevalence and factors associated with atrial fibrillation in patients with chronic rheumatic heart disease.

Methods and materials

A hospital-based cross-sectional study was conducted. A total of 410 patients were selected using a systematic random sampling method. The data were entered into Epi-Data version 4.6 and subsequently exported to SPSS version 26 software for analysis. A binary logistic regression model was applied to identify significant variables related to AF.

Results

In this study, 410 patient charts were reviewed. The prevalence of atrial fibrillation was 43% (95% CI of 38% up to 48%). Male (AOR = 3.81, 95% CI 2.00-7.26), age greater than 30 years (AOR = 7.26, 95% CI 3.93–13.41), heart failure (AOR = 4.65, 95% CI 2.39–9.04), mitral valve stenosis (AOR = 6.36, 95% CI 2.92–13.87), and left atrial diameter enlargement (AOR = 3.41, 95% CI 1.64–7.09) were associated with atrial fibrillation.

Conclusions and recommendations

Atrial fibrillation leads patients to frequent hospital admission and increases hospital mortality. As a result, health care professionals need to pay more attention to and apply more clinical treatment for older patients, those with heart failure, those with mitral valve stenosis, and those with left atrial diameter enlargement-associated causes of atrial fibrillation.

Keywords

Associated factors
Atrial fibrillation
Prevalence
Rheumatic heart disease
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

Rheumatic heart disease (RHD) results from recurrent episodes of acute rheumatic fever, which is an autoimmune response to untreated group A streptococcal pharyngitis that causes inflammation and fibrosis of the heart valves [1, 2]. Severe valvular damage leads to an altered rhythm of heart beats (arrhythmia), which leads to atrial fibrillation [3].

Atrial fibrillation (AF) is a supraventricular arrhythmia associated with uncoordinated atrial activation [2]. Based on the duration of AF episodes, four types of AF are distinguished: paroxysmal AF that terminates spontaneously or with intervention within 7 days of onset, persistent AF that is sustained for greater than days, long-standing persistent AF that persists for > 12 months and permanent. Patient and clinician make a joint decision to stop further attempts to restore and/or maintain sinus rhythm [4].

The prevalence of AF varies based on the characteristics of the population studied and how AF is detected [3]. The global of AF in RHD patients was 32.8%, with substantial heterogeneity, ranging from 4.3 to 79.9% [3, 5–7]. Studies conducted in Spain, Portugal and China showed that the prevalence of AF was 4.4%, 2.5% and 7.9%, respectively [8–10]. In sub-Saharan Africa, the prevalence of AF in patients with rheumatic heart disease ranges from 20 to 35% [3, 11, 12]. A study performed in Ethiopia showed that the prevalence of AF in patients with rheumatic heart disease was 4.3% [13].

AF is the most common sustained cardiac arrhythmia and is a growing public health problem associated with enormous human, economic and social burdens [2, 11]. AF is associated with substantial contributions to all-cause mortality, cardiovascular mortality, sudden cardiac death, stroke, systemic thromboembolism, heart failure and acute coronary syndrome [2]. The of AF increases with age, cardiovascular risk factors and comorbidities such as hypertension, diabetes, congestive heart failure, coronary artery disease and valvular heart disease [14].

Currently, there are three general management strategies for AF: restoring the sinus rhythm, controlling the ventricular rate and preventing stroke [15]. Treatment may include medications to control the prevalence or restore rhythm, surgical procedures and oral anticoagulants to prevent stroke [1, 2, 16–18].

Although different efforts and management methods have been employed for treating AF, it remains a great public health problem worldwide, including in Ethiopia. [19]. Studies on atrial fibrillation in Ethiopia are limited. Therefore, this study aimed to estimate the prevalence of AF and identify factors associated with AF in patients with chronic rheumatic heart disease.

Methods and materials

Study design

An institution based cross-sectional study was conducted.

Study area and period

The study was conducted at public referral hospitals in Bahir Dar city. Bahir Dar is the capital city of the Amhara region in Northwest Ethiopia. The city is located approximately 578 km northwest of Addis Ababa. There are two public referral hospitals in the city: Tibebe Ghion and Felege Hiwot referral hospitals. Tibebe Ghion Specialized Hospital started a service in 2019. Felege Hiwot Referral Hospital started to provide services in 1963. The hospitals provide internal medicine,, ophthalmology, general surgery, obstetrics and gynecology, dermatology, dentistry, psychiatry and other services. The Department of Internal Medicine has inpatient and outpatient units. There were a total of 1,400 chronic rheumatic heart disease patients in both referral hospitals who attended cardiac clinics. The study was conducted from September 1–30/2023 by reviewing patient records collected from January 2021 to December 2023.

Population

Rheumatic heart disease patients who attended cardiac clinics at public referral hospitals in Bahir Dar city.

Eligibility criteria

Inclusion criteria

Patients with clinical and echocardiographic evidence of rheumatic heart disease were included.

Excluded criteria

Patients who do not had complete chart documentation atrial fibrillation and Electrocardiography information.

Sample size, technique and procedure

The sample size was calculated using a single population-proportion formula, and we used the following assumptions: confidence level = 95%, power = 80%, proportion of atrial fibrillation from previous study 0.47 [20] and a final sample size of 410. There are two public referral hospitals in Bahir Dar city. Based on the number of patients at each hospital, the entire sample was distributed to them in a proportionate manner. Patients were subsequently selected from each hospital using a systematic random sampling technique.

Study variable

Dependent variable

Atrial Fibrillation.

Independent variables

Sociodemographic

sex, age, and residence.

Clinical factors

heart failure, chronic kidney disease, h, and valve surgery.

Echocardiography variables

mitral valve stenosis, mitral valve regurgitation, tricuspid valve regurgitation, aortic valve stenosis, aortic valve regurgitation, pulmonary hypertension, left atrial diameter, and left ventricular ejection fraction.

Operational and term definitions

Rheumatic heart disease

Diagnosed by a cardiologist performing echocardiography based on the 2018 World Heart Federation criteria and clinical presentation [21].

Atrial fibrillation

Physician diagnosis with electrocardiography evidence of atrial fibrillation [15].

Heart failure

A complex clinical syndrome that results from structural or functional impairment of ventricular filling or ejection of blood, which in turn leads to the cardinal clinical symptoms of dyspnea and fatigue and signs of HF, namely, edema and rales. Based on the severity of heart failure symptoms, there were four NYHA functional categories. Class I - no limitation of physical activity, Class II - slight limitation of physical activity, class III - marked limitation of physical activity, class IV- if symptoms of HF occur at rest [22, 23].

Pulmonary hypertension

Was suggested by echocardiography when the tricuspid regurgitant jet velocity is ≥ 2.8 m.s− 1 and the pulmonary systolic arterial pressure exceeded 35 mmHg [24].

Left ventricular ejection fraction

a measurement, expressed as a percentage of how much blood the left ventricle pumps out with each heartbeat. Classified as reduced when EF < 40%, mildly reduced when EF was between 41 and 49%, and preserved when EF > 50%. However, for data extraction purposes, we classified patients into those with a reduced LVEF when the EF was < 50% and those with a normal LVEF when the EF was > 50% [25].

Left atrial diameter

represents the anterior posterior dimension of the left atrium measured using e. The normal LA diameter ranges between 20 and 40 mm [26].

Hypertension

Patients were on antihypertensive medications or previously diagnosed with hypertension or SBP and DBP ≥ 140/90 mmHg according to two measurements [27].

Data collection tool and procedure

A pre-developed data extraction checklist was used to collect data from the patient charts. The extraction checklist was prepared by reviewing a variety of studies. The data were collected by health professionals (two nurses and one internal medicine resident). The data collectors collected data on sociodemographic factors, clinical factors, and electrocardiography and echocardiographic findings related to the outcome variable (AF).

Data quality assurance

One day of training was given to the data collectors before the actual data collection. During the training, emphasis was given to techniques for extracting data from patient charts while maintaining confidentiality the data collection was supervised by the principal investigator. -test of the checklist was conducted on 5% of the sample. Based on the, the checklist was revised and edited with necessary modifications.

Data management and analysis

The data were input into Epi-Data version 4.6 and analyzed using SPSS software version 26 after being checked by the principal investigator. The descriptive analysis was performed using simple frequencies and proportions. The multicollinearity between each independent variable was checked. Binary logistic regression was used to assess the association between the dependent and independent variables. All explanatory variables with a p value ≤ 0.25 from the logistic regression model were fitted into the logistic regression model to identify factors associated with AF. Hosmer and Lemeshow’s test was used to test the model’s goodness of fit. During multivariable regression, variables were considered to be significantly associated with AF if their p value was less than 0.05 at the 95% confidence interval. Finally, the results presented in words and tables.

Results

Sociodemographic characteristics

In this study, 410 charts of rheumatic heart disease patients were reviewed. Of those, 256 (69.76%) were females. The median age of the patients was 28 years, and the age range was 15–58 years. The majority of patients, 255 (62.20%), were rural residents (Table 1).

Table 1 Sociodemographic characteristics of patients with rheumatic heart disease to public referral hospitals in Bahir Dar city, Northwest Ethiopia, 2023

Variables	Categories	Frequency	Percent	
Sex	Female	286	69.76	
Male	124	30.24	
Age	≤ 30	206	50.24	
> 30	204	49.76	
Residence	Urban	155	37.80	
Rural	255	62.20	

Clinical characteristics

Among 410 patients with rheumatic heart disease more than half of the patients (286; 69.80%) had heart failure. The majority of the patients had no hypertension, chronic kidney history of valvular surgery (Table 2).

Table 2 Clinical characteristics of patients with rheumatic heart disease admitted to public referral hospitals in Bahir Dar City, Northwest Ethiopia, 2023

Variables	Categories	Frequency	Percent	
Heart failure	No	124	30.20	
Yes	286	69.80	
Chronic kidney disease	No	404	98.54	
Yes	6	1.46	
Hypertension	No	398	97.07	
Yes	12	2.93	
History of valvular surgery	No	383	93.41	
Yes	27	6.59	

Echocardiographic characteristics

This study showed that more than half of the patients had most patients had pulmonary hypertension 72.20%). The majority of patients had enlarged left atrial diameters 29471.70%), and most patients’ left ventricular ejection fractions were normal 373 90.98%)(Table 3) .

Table 3 Echocardiographic characteristics of patients with rheumatic heart disease admitted to public referral hospitals in Bahir Dar City, Northwest Ethiopia, 2023

Variables	Categories	Frequency	Percent	
Mitral stenosis	No	116	28.30	
Yes	294	71.70	
Mitral regurgitation	No	86	20.98	
Yes	324	79.02	
Tricuspid valve regurgitation	No	149	36.34	
Yes	261	63.66	
Aortic valve stenosis	No	365	89.02	
Yes	45	10.98	
Aortic valve regurgitation	No	319	77.80	
Yes	91	22.20	
Pulmonary hypertension	No	114	27.80	
Yes	296	72.20	
Left atrial diameter	Normal (< 40 mm)	116	28.30	
Enlarged (≥ 40 mm)	294	71.70	
Left ventricular ejection	Reduced (< 50%)	37	9.02	
Normal (≥ 50%)	373	90.98	

Prevalence of atrial fibrillation

The prevalence of atrial fibrillation in this study was 43%, with a 95% CI of 38% up to 48%.

Factors associated with atrial fibrillation

Fifteen possible variables believed to be associated with AF were entered into the variable binary logistic regression model. were sex, age, residence, heart failure, chronic kidney disease, hypertension, history of valvular surgery, mitral valve stenosis, mitral valve regurgitation, tricuspid valve regurgitation, aortic valve stenosis, aortic valve regurgitation, pulmonary hypertension, left atrial diameter and left ventricular ejection.

According to the results of the variable logistic regression analysis, nine variables were considered to be significant at a level ≤ 0.25. All these variables were entered into a multivariable binary logistic regression model. According to the final logistic regression model, five variables were significantly associated with AF p values less than 0.05 sex, age, heart failure, mitral stenosis and left atrial diameter.

In this study, males were 3.81 times more likely to develop atrial fibrillation than females (AOR = 3.81, 95% CI 2.00-7.26). Patients aged > 30 years were 7.26 times more likely to develop atrial fibrillation than patients aged ≤ 30 years (AOR = 7.26, 95% CI 3.93–13.41). Patients who had heart failure were 4.65 times more likely to develop atrial fibrillation than patients who had no heart failure (AOR = 4.65, 95% CI 2.39–9.04). Patients who had mitral valve stenosis were 6.36 times more likely to develop atrial fibrillation than patients who did not have mitral valve stenosis (AOR = 6.36, 95% CI 2.92–13.87). Patients who had enlarged left atrial diameter were 3.41 times more likely to develop atrial fibrillation than patients who had a normal left atrial diameter (AOR = 3.41, 95% CI 1.64–7.09)(Table 4).

Table 4 Logistic regression analyses of AF among patients with rheumatic heart disease admitted to public referral hospitals in Bahir Dar City, Northwest Ethiopia, 2023

Variables	Category	AF	COR(95% CI)	AOR(95% CI)	Value	
Yes	No	
Sex	Female	109	177	1	1		
Male	67	57	1.91(1.24–2.92)	3.81(2.00-7.26)	< 0.001*	
Age category	≤ 30	53	153	1	1		
> 30	123	81	4.38(2.88–6.67)	7.26(3.93–13.41)	< 0.001*	
Heart failure	No	17	107	1	1		
Yes	159	127	7.88(4.49–13.83)	4.65(2.39–9.04)	< 0.001*	
History of valvular surgery	No	159	224	1	1		
Yes	17	10	2.39(4.49–13.83)	3.04(0.99–9.37)	0.052	
Mitral valve stenosis	No	11	105	1	1		
Yes	165	129	12.21(6.29–23.68)	6.36(2.92–13.87)	< 0.001*	
Mitral valve regurgitation	No	42	44	1	1		
Yes	134	190	0.74(0.46–1.19)	1.42(0.77–2.63)	0.254	
Pulmonary hypertension	No	11	103	1	1		
Yes	165	131	3.06(1.95–4.79)	0.84(0.44–1.63)	0.620	
Left atrial diameter	Normal	17	99	1	1		
Enlarged	159	135	6.86(3.91–12.05)	3.41(1.64–7.09)	< 0.001*	
Left ventricular ejection	Reduced	26	11	1	1		
Normal	150	223	0.28(0.14–0.59)	0.79(0.32–1.96)	0.619	

Discussion

This study revealed that the prevalence of atrial fibrillation among rheumatic heart disease patients was 43%, with a 95% CI of 38% up to 48%. The results showed that nearly half of the patients with rheumatic heart disease were at risk of AF. This finding was similar to that of a study conducted in Ethiopia at St. Paul’s Hospital Millennium Medical College, which showed that the prevalence of was 43.5% [28].This similarity might be both studies used similar study designs and diagnostic approaches for AF.

studies conducted at Gondar University Hospital and Jimma Zone, which showed that the prevalence of was 22.8%, 4.3%, and 4.3%, respectively [13, 29]. This discrepancy might be due to the difference in sample size. Studies conducted at Gondar University Hospital and in the Jimma Zone used smaller sample sizes than did the current study.

much than those of studies conducted in Spain (4,4%) [8], Portugal (2.50%) and China (7.90%) [9, 10] and a study conducted at the global level (32.8%) [3, 6]. The difference might be due to differences in sociodemographic conditions, clinical setup, quality of care, and patient management protocols.

The current finding was less than that of a study conducted at the Tikur Anbessa (46.8%) [30]. This disparity may arise from the fact that all patients at Tikur Anbessa were referred from different parts of the country and more severe cases. The current study revealed a lower result than studies conducted in Sub-Saharan Africa (46%) [31–34]. This difference might be due to the study setting because the study was conducted in sub-Saharan Africa and was community-based, but the current study was institution-based.

This study showed that men were more likely than women to develop AF. These findings are in line with those of a study conducted in China [35]. Men are more prone than women to be exposed to conditions, including and hypertension, which might increase the prevalence of AF. [36]. The findings of this study showed that patients aged > 30 years were more likely to develop AF than patients aged ≤ 30 years. similar to those of studies conducted in Nepal and Turkey [5, 37]. When age increases, patients are exposed to more comorbidity that precipitates the occurrence of AF.

Patients who had heart failure were more likely to develop AF than patients who had no heart failure. Similar to those of studies conducted in India and Australia [38–41]. Heart failure can increase the risk of AF development through the elevation of cardiac filling pressure, increased interstitial fibrosis, deregulation of intracellular calcium, and autonomic and neuroendocrine dysfunction, which promotes structural remodeling and atrial fibrosis, thus altering atrial conduction properties and promoting AF.

Patients who had mitral valve stenosis were more likely to develop AF than patients who had no mitral valve stenosis. similar to those of a studies conducted in India [42, 43]. Mitral valve disease causes left atrial dilatation, which is a common substrate for AF. Patients who had enlarged left atrial diameter were more likely to develop AF than patients who had a normal left atrial diameter. This result was consistent with studies conducted in other countries [44–46]. also consistent with the American Heart Association guidelines [47]. In patients with left atrial enlargement, additional blood accumulates at the atrium, which causes the atrium to fibrillate. As a result, patients with left atrial diameter enlargement develop AF. Left atrial enlargement with a consequent decrease in left atrium function represents maladaptive structural and functional remodeling that in turn promotes electrical remodeling and a milieu conducive to the incidence of AF.

Limitation of the study

Since the data were gathered from a secondary source, certain important variables, such as patient behavioral variables, which could be associated with atrial fibrillation, were missed.

Conclusion

The results of this study showed a high prevalence of AF. As a result, health care professionals should pay special attention and provide clinical care for patients with associated factors of AF, such as sex, advanced age, heart failure, mitral valve stenosis, and left atrial diameter enlargement, which increase the prevalence of AF.

Acknowledgements

We want to thank Bahir Dar University for the opportunity and financial aid. We would like to extend our sincere thanks to the employees of the Felege Hiwot referral hospital and Tibebe Ghion referral hospital (research coordinator, medical ward coordinator, cardroom workers, and others) for their help during the data collection for this study.

Author contributions

Adanech Mengie, Eleni Admassu, Desiyalew Habtamu, Alemshet Yirga, Kebadnew Mulatu and Tadios Lidetu have equal contribution on organized the original investigation; coordinated the collection of data; analysis and writing the report, supervision in the design of the study and statistical analyses and drafted and revision of the Manuscript. All authors read and approved the final manuscript.

Funding

The funding source for the current study was the Bahir Dar University College of Medicine and Health Sciences. The funder had no role in the data collection, analysis, drafting of the manuscript, preparation, /or publication of this paper.

Data availability

The data used to support the findings of this study are available from one of the Authors.

Declarations

Ethical approval

Ethical approval was obtained from the Institutional Review Board (IRB) of the Bahir Dar University College of Medicine and Health Sciences. A letter of cooperation was written for public referral hospitals in Bahir Dar city with a letter written on December 19, 2023, with a protocol number of 14889/24. Due to the nature of the study (chart review), informed consent was waived by the Ethical Review Committee (ERC) of the Felege Hiwot and Tibebe Ghion referral hospitals to review charts of rheumatic heart disease patients. The confidentiality of the information was ensured throughout the study by excluding names and patient medical records as identification in the data extraction form, and the data were used only for the proposed study. The current study adhered to the Helsinki Declaration.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Abbreviations

AF Atrial Fibrillation

AR Aortic regurgitation

AS Aortic stenosis

BMI Body Mass Index

CHF Congestive Heart Failure

CRHD Chronic Rheumatic Heart Disease

ECG Electrocardiography

ECHO Echocardiography

eGFR Estimated glomerular filtration rate

ICU Intensive Care Unit

LMICs Low and Middle Income Countries

LVEF Left Ventricular Ejection Fraction

MR Mitral regurgitation

MS Mitral Stenosis

MVA Mitral valve area

NYHA New York Heart Association

OACs Oral anticoagulants

OPD Outpatient Department

PH Pulmonary hypertension

SSA Sub Saharan Africa

TGSH Tibebe Ghion Specialized Hospital

TR Tricuspid Regurgitation

WHF World Heart Federation

WHO World Heart Organization.

The original online version of this article was revised: the affiliation details for Authors Kebadnew Mulatu and Tadios Lidetu were incorrect and it has been updated.

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